Biliary system
Prof. Weilin Wang wam@zju.edu.cn
Department of Hepatobiliary Pancreatic Surgery
The First Affiliated Hospital
1
Anatomy of Biliary System
2
Methods of Investigation
3
Disorders of Gallbladder
4
Disorders of Bile Duct
5
Case discussion
1
Anatomy of Biliary System
Extrahepatic Biliary Tract
Bifurcation
Common hepatic duct
Common bile duct
Cystic duct
Gallbladder
Transportation of Bile

The liver secrete bile, bile flow
from liver to right and left
hepatic ducts.

These ducts drain into the
common hepatic duct.

The common hepatic duct
then joins with the cystic duct
to form the common bile duct.
Transportation of Bile

About 50 percent of the bile
produced by liver is first stored
and concentrated in gallbladder.

When food is taken, the
gallbladder contracts and
release stored bile into the
duodeum to help digest the fats.
Calot triangle

The triangle is bounded by the
cystic duct, the common
hepatic duct, and the inferior
border of the liver.

Important structures including:
the cystic artery, the right
hepatic artery, and the cystic
duct lymph node.
Papilla of Vater



Tthe opening of the bile
duct and panceatic duct
in the descending part of
the duodenum.
Through the papilla, bile
and pancreatic juice pass
to to bowel.
obstructive jaundice or
pancreatitis will happen
when papilla of Vater was
blocked by stones and
tumors,
Normal gallbladder
Gallbladder Anatomical Variants

Agenesis of the gallbladder is extremely rare,
with a prevalence of 0.03-0.07 percent.

Double gallbladder occurs in about 0.03 per cent,
usually with a shared cyctic duct, and the
accessory gallbladder is often diseased.
Variations of biliary branching

A Typical anatomy of the
confluence.

B Trifurcation of left, right
anterior, and right posterior
hepatic ducts.

C Aberrant drainage of a right
anterior (C1) or posterior (C2)
sectoral hepatic duct into the
common hepatic duct.
2
Methods of Investigation
Methods of investigation

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Ultrasonography (B-US)
CT, Computed Tomographic
Magnetic Resonance Cholangiopancreatography
Endoscopic Retrograde Cholangopancreatography
Percutaneous Transhepatic Cholangiography
T-tube cholangiography
Radiographs
Intraoperative cholangiography
Endoscopic ultrasound
……
B-US

Fast, real-time, non-invasive, and no ionizing radiation,
cheap and could be available even in countryside.

95% sensitivity for detection of cholelithiasis.
--Found a mobile, hyperechoic with acoustic shadowing

>90% sensitivity for detection of acute cholecystitis.
--Gallbladder wall thickening, pericholecystic fluid
Normal Gallbladder
Gallbladder, with sludge
and stone present
CT scan

Gallstones can be seen on CT, but it is not used
primarily for this purpose.

CT can be used in situations where ultrasound is difficult
--such as in obese patients. It can also be used if the ultrasound is
not definitive.
Plain CT shows multiple gallstones.
Multiple stones were found in the left intrahepatic bile duct.
MRCP

Becoming a more viable imaging technique

New tool for non-invasive evaluation of the pancreatic
and biliary ductal systems.

Gradually replacing PTC and ERCP for diagnostic
purposes.
Pancreatic duct
Common bile duct
MRCP showed slight dilation of CBD
Stones in CBD
Stones was detected in the bile duct by MRCP.
ERCP
Left: The endoscope
was introduced to the
papilla of Vater and
contrast medium was
injected into common
bile duct.
Right: Radiographic
result after the contrast
medium was injected
into the CBD.

ERCP is the primary method of direct cholangiography, and has therapeutic potential. It also
allows for examination of the upper GI tract, the papilla of Vater, and the pancreatic duct.
ERCP: Instruments can also be inserted through the scope to remove stones, insert stent,
tissue biopsy, and other treatments.
Stones in CBD
Endoscope
Pancreatic duct
ERCP: showing slightly dilated common bile duct with
calculus and normal pancreatic duct.
Large stone was drawing out from CBD during ERCP was performing.
Show the procedure of removal the stones using endoscope .

ERCP.wmv
PTC

The catheter was placed
into the intrahepatic bile
duct through patient’s
skin guiding by B-US
and fixed on the skin.

The radiographic image
was taken.

Obstructive lesion can
be seen in this picture.
Obstructive lesion
Before
After

Left : After injection of dye, showing a large gallstone trapped in the duct.

Right: After removal of the stone through the drainage catheter.
T-tube cholangiography

Postoperatively

Injection of contrast medium through a T-tube catheter
placed in the CBD

Easy way to show whether there are remaining stones or
any stricture
T-tube graphy
Radiographs

Old technique used in the past, widely replaced by the
ultrasound and MRCP.

Can be used to visualize calcified stones by abdominal
x-ray film.
Stones
Stones
Abdominal x-ray demonstrating stones in the gallbladder
3
Disorders of Gallbladder
Disorders of Gallbladder
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Acute cholecystitis
Gallbladder stones and sludge
Adenomyomatous hyperplasia
Gallbladder polyps
Gallbladder carcinoma
……
Acute Cholecystitis

Calculous cholecystitis: over 90%

Clinical manifestation:
--Pain in right upper quadrant
--Radiates to right shoulder & back
--Nausea & vomiting
--Chill and/or fever
--Abdominal tenderness
--Murphy's sign (+)
Acute Cholecystitis: B-US
The gallbladder contains small stones in the neck and its wall shows
oedematous thickening (>5 mm thickness).

Other B-US signs are:
--Gallbladder over distension
--Pericholecystic fluid
--GB wall thickening
-- ……
Acute Cholecystitis: CT

Less accurate than B-US

The CT findings :
--Gallbladder wall thickening
--Subserosal oedema
--Gallbladder distension
--Pericholecystic fluid
--Gallstones
Sludge
•Fine, nonshadowing dependent echoes.
•Composed of calcium bilirubinate granules, cholesterol crystals.
•Gallstones will develop in 5-15 percent.
Sludge
Stone
Gallbladder, with sludge and stone present
Gallbladder polyps

The majority of polyps are cholesterol

Cholesterol polyps are usually 210mm in size
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They appear as small echogenic
nonshadowing foci adherent to the
gallbladder wall

Lack of mobility indicates polyp
Gallbladder-Adenomyomatosis

The affected segment
often contains bright
echoes

Often associated with
‘comet-tail’
Mirrizzi syndrome

Common hepatic duct obstruction
caused by an extrinsic compression from
an impacted stone in the cystic duct.

May result in biliary obstruction and
jaundice

If not recognized preoperatively, it can
result in significant morbidity and
mortality
Indication for Cholecystectomy

Symptomatic cholelithiasis

Non-functioning gallbladders (Full of stones)

Malignant considered: GB polyps (>1.2cm) or others
Open Cholecystectomy
The first case was performed in 1882
One safe and effective method
Direct visualization and palpation
Laparoscopic Cholecystectomy
A less invasive way to remove the
gallbladder
Smaller incisions and less pain
Shorter hospital stay and a shorter
recovery time
Laparoscopic Cholecystectomy
Gallbladder Carcinoma

Gallbladder carcinoma is associated with
stones in over 90% of patients
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There is a female to male ratio of 3:1
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Few patient was diagnosed prior to surgery
Gallbladder Carcinoma
Gallbladder
Carcinoma
Gallbladder Carcinoma
TNM classification
TNM classification
Quiz


Direct invasion of the liver
by gallbladder cancer in a
66-year-old woman
Should differentiate
gallbladder cancer from
acute cholecystitis
T?N?M?
Treatment

Radical surgery including segment liver resection, bile
duct resection and extensive lymphadenectomy
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Poor prognosis in patients with unresectable tumor
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External radiation therapy may provide palliative benefit.
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5-Fu and Gemcitabine can be used as chemotherapy.
 Gall-Bladder.mp4
 LC.mp4
4
Disorders of Bile Duct
Disorders of Bile Duct
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AOSC
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Choledocholithiasis/Hepatolithiasis
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Choledochal cyst
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Cholangiocarcinoma
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Pancreatic and ampullary tumor
AOSC
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Acute obstructive suppurative Cholangitis (AOSC)
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Emergency disease carries high mortality
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Common obstructing factors: stones, tumor
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Complete obstruction and suppurative infection
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May result in septicemia & septic shock; MSOF
Clinical manifestation
Charcot triad
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Abrupt onset of pain in upper quadrant
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Chill, high fever, may nausea and vomiting
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Jaundice
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May shock, and/or Acute renal failure and ARDS
Treatment
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Correct the fluid and acid-base balance
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Systemic administration of antibiotics
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Anti-shock treatment
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Drain the biliary tract: ERCP or PTCD

Emergency operation
Choledocholithiasis/Hepatolithiasis
Small shadowing stone (Arrow) in dilated bile duct.
Choledocholithiasis/Hepatolithiasis
CT show multiple stones in hepatic bile duct
Choledocholithiasis/Hepatolithiasis
Stones
ERCP: demonstrating stone in the duct (arrow)
Choledochal cysts

Cystic dilatation of the extrahepatic bile ducts

Female to male is about ration 4:1

The majority are now diagnosed in childhood
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Classified into five types

Associated with various biliary tumors
Type I
Type II
Type III
Type IV
Type V
Choledochal cysts
CT
MRCP
Bile Duct Cancer
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Cholangiocarcinoma
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Pancreatic and ampullary tumours

……
Cholangiocarcinoma
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Most commonly at the hepatic duct bifurcation (Klatskin
tumor)
Present with jaundice
Clinical Presentation:
--Jaundice (around 90% )
--Pruritus
--fever
--mild abdominal pain
--fatigue
--……
Surgical resection offer a chance for long-term disease-free
survival
Cholangiocarcinoma

B-US: nodules or focal bile duct wall thickening

CT: nodules are usually isodense or slightly
hypodense

MRCP: show the proximal extent of the
stricturing
Small hilar cholangiocarcinoma (Arrowhead) producing obstruction of the right
posteral sectoral duct (Short arrow). Right anterior sectoral duct (long arrow) and
left hepatic duct. (A) Thick oblique coronal MRCP. (B) Axial portal phase CT (C)
Longitudinal US. (D) Transverse color Doppler US (Open arrow, normal left portal
vein).
Bismuth Classification
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I
III
II
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IV
Type I: confined to the common
hepatic duct
type II: involve the bifurcation
Type IIIa and IIIb: extend into
either the right or left
secondary intrahepatic ducts,
respectively
Type IV: involve the secondary
intrahepatic ducts on both
sides
Quiz
Type?
Treatment

Distal lesions are usually treated with Whipple
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Intrahepatic lesions are treated by hepatic resection
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Perihilar (Klatskin) tumor:
--Type I and II: Resection of the extrahepatic bile ducts and gallbladder
--Type III and IV: Curative resection is difficult

Radiation therapy improves survival for patients
Typical operation I
Resection of the extrahepatic bile
ducts and gallbladder with 5-10 mm
bile duct margins, and regional
lymphadenectomy with Roux-en-Y
hepaticojejunostomy.
Typical operation II: Whipple
Before
After
The head of the pancreas,
the entire duodenum, a
portion of the jejunum, the
distal third of the stomach,
and the lower half of the
common bile duct are
excised, usually to relieve
obstruction caused by
tumors. Continuity is
reestablished between
the biliary, pancreatic, and
GI systems.
5
Case discussion
Case: Clinical manifestation
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42-year-old woman patient was admitted to our emergency
department because of repeated upper abdominal pain for 2
years and aggravated for three days.
With nausea, vomiting, chill and fever. The highest temperature
reached to 39.5℃. She also found dark urine and skin turned
yellow.
PE: BP 85/52 mmHg. Yellow stained was found in the skin and
sclera.
Which examination should be performed for diagnosis?
Examination needed
 Laboratory
test:
--Blood routine test
--Liver function and serum electrolyte
--Serum Amylase
 Imaging
test:
--B-US (First choice. Why?)
--MRCP
--CT
Examination finding
 Laboratory
test:
--BRT: WBC 23.4*10E9 Neuophil 94% Hgb 95g/l
--Liver function: ALT 154 U/l TB/DB 194/153 mmol/l
--Serum Amylase : Normal
 Imaging
--MRCP
test:
Diagnosis
Acute Cholecystitis?
No
Gallstone pancreatitis?
No
Cholangitis?
Yes
AOSC, Septic shock
Treatment
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Anti-shock treatment
Most important!!
Antibiotic drug
Drainage: Emergency ERCP
was performed and ENBD was
placed
…….
CT scan show multiple stone in CBD and hepatic duct.
The catheter can be seen.
Treatment
When the general condition is stable and
the TB level declined to 50mmol/l,
choledocholithotomy was carried out and
stones were removed.
 The patient recovery very well without any
episode.

Questions?